PCI in Stable CAD of Limited Benefit

Action Points

Compared with medical therapy, percutaneous coronary intervention (PCI) conferred only one benefit in those with stable coronary artery disease: relief of angina.

Note that PCI was not associated with a reduced risk of mortality, cardiovascular death, nonfatal myocardial infarction, or revascularization compared with optimal medical therapy.

Compared with medical therapy, percutaneous coronary intervention (PCI) conferred only one benefit in those with stable coronary artery disease: relief of angina, a meta-analysis showed.

PCI held no edge over optimal medical therapy in all-cause mortality, the primary outcome (RR 0.85, 95% CI 0.71 to 1.01), according to Sripal Bangalore, MD, MHA, from New York University School of Medicine in New York City, and colleagues.

The invasive procedure also did not significantly improve cardiac death, nonfatal myocardial infarction (MI), or repeat revascularization, they reported in the August issue of Circulation: Cardiovascular Interventions.

The one benefit researchers observed in patients undergoing PCI compared with those receiving optimal medical therapy was a significant reduction in angina (RR 1.20, 95% CI 1.06 to 1.37).

"In patients with stable coronary artery disease, there is no definitive evidence of an added benefit of PCI to reduce the risk or mortality, cardiac death, nonfatal MI, and need for revascularization, when compared with medical therapy alone," Bangalore and colleagues concluded.

These results mostly mirror those of the COURAGE trial. When COURAGE was published in 2007, it took the medical community by surprise. Many had assumed that medical management of stable patients was inferior to PCI, given the advancements in perioperative care and drug-eluting stents.

But COURAGE proved them wrong. As with the current meta-analysis, COURAGE found no significant differences in the primary endpoint of death and MI. Nor did it find any differences in rates of individual endpoints including stroke, death, MI, or hospitalization for acute coronary syndrome.

But COURAGE did not find that PCI was better than medical therapy for the relief of angina.

In the current meta-analysis from Bangalore and colleagues, the risk of all-cause mortality was somewhat attenuated when the researchers restricted their analysis to recent studies with a high proportion of stenting and in which more aggressive medical therapy was employed (BARI 2D, COURAGE, MASS-2 and JSAP (Japanese Stable Angina Pectoris).

For example, the relative risk of all-cause mortality went from 0.85 in the initial analysis to 0.93 in the restricted analysis, which was an improvement but still not significant (95% CI 0.78 to 1.11).

Of note is that the benefits of PCI increased with longer follow-up, particularly after 5 years, but they still did not reach significance. This was true for all-cause mortality, cardiovascular death, and nonfatal MI.

COURAGE also showed improved benefits of PCI over the longer term.

All 12 trials included in this meta-analysis were randomized, but there was considerable heterogeneity, Bangalore and colleagues noted.

The median age ranged from 54 to 64, but men were in the majority in all trials (range: 63% to 100%).

The researchers also made notice of the fact that no standard definition of coronary artery disease exists. "The trials included in this meta-analysis had varying angiographic definitions for significant coronary stenosis and only a minority clearly described a requirement for clinical symptoms of angina," they wrote.

In that regard, they excluded trials that enrolled patients within 1 week of an acute coronary syndrome.

The limitations of the study include the subjective nature of reporting freedom from angina, the inability to adjust for medication dosage, and the heterogeneity of 2 decades worth of trials.

Also, because of the heterogeneity, the authors said it is unknown whether these results are generalizable.